A visit from a Russian patient brings up cultural competency issues for Fred N. Pelzman, MD.

When she finally made it through the registration line, got checked in, and was placed in the exam room after the long walk down the hallway with her walker, she said she was there to see me about her blood pressure, and how terrible she felt in the mornings.

She is a native Russian speaker, and I got our interpreter service on the telephone and proceeded to ask her about what she has been feeling, what her blood pressure readings have been, and what she might have been doing differently that made her come in today.

She said that some mornings she took her blood pressure and it was "very low" and she felt bad, so she split one of her blood pressure pills in half, and then she felt better. On other mornings, her blood pressure was "too high" and she felt bad, and she would take "an extra piece" of one of her blood pressure pills, and then she felt better.

Despite multiple attempts to figure out what was going on, I (and the Russian medical translator on the telephone) remained confused about the story she was telling us. I would ask a simple Yes-or-No question, and the patient and the translator would then have a long, drawn-out conversation, and then the Russian translator would ultimately come back with "Yes" or "No." I could not figure out why her blood pressure might be high one morning and low the next.

At her previous visit several months ago, it had been noted that her blood pressure was running on the low side, so the dose of one of her medications was decreased. It turns out that she has also been going to see a local provider in her neighborhood in Brooklyn, Brighton Beach, and he increased the dose of the medication back up, apparently based on some reading in the office there.

In addition, she then brought out an herbal supplement, in a bottle covered in Cyrillic type, which she said she had bought through a newspaper ad, noting that it was the "German kind" (not the American kind, which she said never works).

We were finally able to figure out that this was a combination product containing Valerian root along with several other herbs, and she said she took this whenever her blood pressure was too low, too high, or if she just did not feel right.

So the question is, do I raise the dose of her blood pressure medicine? Do I lower the dose of her blood pressure medicine? Do I do nothing?

Clearly, I am culturally incompetent. Despite the use of a trained medical translator on the phone, I am unable to penetrate what is truly happening with her healthcare at her home, in her community, and what her cultural and social determinants of health bring to the mix.

Several years ago, along with several other partners in our practice I was asked to speak at a medical school conference on the challenges of cross-cultural medicine and cultural competence. We spoke about many of the issues involved in trying to provide the optimal care to patients from worlds different from our own.

There were many questions about language and cultural differences, community practices, and culture-specific medical beliefs.

One of my partners on the panel, who is from Puerto Rico, made the incredibly important point that just speaking Spanish wasn't enough to take care of all Spanish-speaking patients. While it helps, she said, you need to know that patients from the Dominican Republic are different from patients from Mexico, are different from patients from Spain, are different from patients from Peru.

And even within Puerto Rico itself, there are many different cultures, so she said that she cannot begin to comprehend all that is necessary to truly understand someone's cultural belief system. Just because she can speak Spanish doesn't mean that she can know them.

If we are to bring medical care back to being centered around the patient, then we have to assume that of paramount importance are these elements of their cultural history, their cultural beliefs, and even the culture of their neighborhood, to helping them navigate and thrive in our complex healthcare system.

So am I ever going to be able to truly understand exactly what my Russian-born patients living in Brighton Beach are really thinking and doing?

The medical technician who works in my office is Russian, and she will often offer some insights, explaining -- or trying to explain -- to me how things work in Brighton Beach.

Everyone has another doctor, everyone takes medicines and supplements they buy in local shops, online, from newspaper ads, and overseas.

By "everyone," she is obviously generalizing; she like all of us brings inherent biases (she is from a different region of Russia than this patient), but it does offer a little bit of help in trying to get me to bend my own biases towards a more understanding position.

As we expand on patient-centered medical care, we need to enlist community health workers who live among our patients, walk the same streets, shop in the same stores, eat the same food, have the same barriers to good nutrition and exercise, and who may have figured out how to work the system, to help us take optimal care of our patients.

It will never be a complete solution, a perfect answer, but it certainly has the potential to enhance our ability to help our patients make healthy choices.

Knowing that the transportation service picked her up 1 hour late and how hard it is to travel over 2 hours through morning rush-hour traffic to get to our practice should inspire us to help her figure out the best solution to her blood pressure medication conundrum.

I need to know that she is still going to take Valerian and she is still going to see her local doctor, almost no matter what I might think or say.

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